By Counterforce Health Team in Cresemba (isavuconazole) —

How to Get Cresemba (Isavuconazole) Covered by Humana in Washington: Complete Forms, Appeals & Portal Guide

Quick Start: Getting Cresemba Covered by Humana in Washington

Cresemba (isavuconazole) requires prior authorization from Humana and must be filled through their specialty pharmacy network. Most approvals happen within 7 days when you submit complete clinical documentation showing invasive aspergillosis or mucormycosis diagnosis, plus evidence that voriconazole failed or can't be used. Start today by: 1) Confirming your plan covers specialty drugs, 2) Having your doctor submit the PA request through Humana's provider portal with infectious disease consultation notes, and 3) Enrolling with CenterWell Specialty Pharmacy. If denied, Washington residents have strong appeal rights including external review through an independent organization.

Table of Contents

Verify Your Plan Coverage

Before starting the prior authorization process, confirm your Humana plan includes specialty drug coverage and check Cresemba's formulary status.

Steps to verify coverage:

  1. Log into your MyHumana account or call member services at 1-800-833-2364
  2. Use Humana's drug list tool to search for "isavuconazole" or "Cresemba"
  3. Note the tier placement (typically Tier 4 specialty) and any restrictions
  4. Confirm your specialty drug benefit hasn't reached annual limits
Note: Cresemba is generally placed on Humana's highest specialty tier, requiring prior authorization and step therapy documentation showing voriconazole failure or contraindication.

Required Forms and Documentation

Core Prior Authorization Form

Your doctor must submit the "Request for Medicare Prescription Drug Coverage Determination" form, available through Humana's provider portal.

Essential Clinical Documentation

For invasive aspergillosis or mucormycosis, include:

  • Diagnostic evidence: Culture results, galactomannan testing, PCR, or tissue biopsy showing fungal infection
  • Risk factors: Immunosuppression status, hematologic malignancy, transplant history, or ICU admission
  • Infectious disease consultation: Required by most Humana plans for antifungal approvals
  • Prior therapy documentation: Evidence of voriconazole failure, intolerance, or contraindication
  • ICD-10 codes: B44.0 (invasive aspergillosis) or B46.x series (mucormycosis)

Medical Necessity Letter Template

Your infectious disease specialist should include:

Patient [Name] has confirmed [invasive aspergillosis/mucormycosis] based on [specific diagnostic evidence]. 
Previous treatment with voriconazole was [discontinued due to/contraindicated because of] [specific reason].
Isavuconazole is medically necessary as [first-line alternative/salvage therapy] per current guidelines.
Expected treatment duration: [timeframe] with monitoring via [specific plan].

Submission Portals and Methods

Online Submission (Preferred)

Providers should use:

  • Humana Provider Portal pharmacy section
  • Search tool to confirm current PA requirements for isavuconazole
  • Electronic submission with document upload capability

Alternative Submission Methods

Method Contact Notes
Fax 877-486-2621 Include cover sheet with member ID
Phone 800-555-CLIN (2546) Mon-Fri, 8 AM-8 PM local time
Mail Address from denial letter Allow extra processing time
Tip: Electronic submissions through the provider portal typically process faster and provide automatic confirmation receipts.

Specialty Pharmacy Enrollment

Cresemba must be dispensed through Humana's specialty pharmacy network, primarily CenterWell Specialty Pharmacy.

Enrollment Process

  1. Provider submission: Doctor faxes prescription to CenterWell at 1-877-405-7940
  2. Patient registration: Create account at CenterWell or use MyHumana credentials
  3. Insurance verification: CenterWell confirms coverage and processes PA if needed
  4. Delivery setup: Choose home delivery or clinic shipment options

Required information for enrollment:

  • Complete prescription with diagnosis
  • Insurance card and member ID
  • Provider NPI and DEA numbers
  • Preferred delivery address and contact information

CenterWell contact: 1-800-486-2668 for enrollment assistance and financial support programs.

Medical Necessity Requirements

Clinical Criteria for Approval

Humana typically approves Cresemba when documentation shows:

  • Confirmed diagnosis of invasive aspergillosis or mucormycosis using accepted clinical criteria
  • Step therapy compliance: Voriconazole tried and failed, or documented contraindication/intolerance
  • Specialist involvement: Infectious disease consultation supporting isavuconazole use
  • Appropriate dosing: Loading dose (372 mg every 8 hours × 6 doses) followed by maintenance (372 mg daily)

Common Documentation Gaps

Strengthen your submission by avoiding these issues:

  • Missing infectious disease consultation notes
  • Incomplete prior therapy documentation
  • Vague diagnostic evidence without specific test results
  • Lack of treatment duration and monitoring plan
From our advocates: We've seen approvals happen within 48 hours when the infectious disease specialist clearly documents why voriconazole isn't suitable and includes recent culture or galactomannan results. The key is being specific about the clinical rationale rather than just stating "patient needs isavuconazole."

Appeals Process in Washington

If your initial PA request is denied, Washington state provides robust appeal rights through multiple levels.

Internal Appeals (First Step)

Timeline: Submit within 60 days of denial notice Process:

  1. Use denial letter instructions to file internal appeal
  2. Include additional clinical evidence addressing denial reason
  3. Request expedited review if urgent (72-hour decision)

External Review (Independent Review)

Washington residents can request external review by an Independent Review Organization (IRO) if internal appeals fail.

Key benefits:

  • Independent medical specialists review your case
  • Decision is binding on Humana
  • 180 days from final internal denial to request
  • Standard review: 30 days; expedited: 72 hours

How to request:

  1. Contact Washington State Insurance Commissioner at 1-800-562-6900
  2. Submit external review request form
  3. Include all medical records and denial letters
  4. IRO assigned automatically from state registry

Appeal Letter Template

[Date]
Humana Appeals Department
[Address from denial letter]

RE: Appeal for Cresemba (isavuconazole) Coverage
Member ID: [Your ID]
Claim/PA Number: [Number]

I am appealing your denial of coverage for Cresemba (isavuconazole) dated [date]. 
The denial reason "[specific reason]" does not reflect the medical necessity of this treatment.

My infectious disease specialist has determined this medication is essential for treating 
my confirmed invasive [aspergillosis/mucormycosis]. Attached documentation includes:
- Updated clinical notes and diagnostic results
- Evidence of voriconazole failure/contraindication  
- Current treatment guidelines supporting isavuconazole use

Per Washington state regulations, I request reconsideration of this decision.
Please contact me at [phone] with questions.

Sincerely,
[Your name]

Support Contacts and Resources

Humana Member Services

  • Phone: 1-800-833-2364
  • Hours: 8 AM-8 PM, 7 days a week
  • Online: MyHumana member portal

Provider Support

  • Prior Authorization Line: 1-800-555-CLIN (2546)
  • Pharmacy Services: 1-800-448-6262
  • CenterWell Specialty: 1-800-486-2668

Washington State Resources

Common Denial Reasons and Solutions

Denial Reason Solution Required Documentation
"Not medically necessary" Submit ID consult notes with clinical rationale Specialist letter, diagnostic evidence
"Step therapy not met" Document voriconazole failure/contraindication Prior therapy records, adverse event notes
"Insufficient documentation" Provide complete clinical picture Culture results, imaging, risk factors
"Non-formulary drug" Request formulary exception Medical necessity letter, guideline citations

Frequently Asked Questions

Q: How long does Humana take to approve Cresemba prior authorization? A: Standard decisions within 7 calendar days starting January 2026. Expedited reviews for urgent cases decided within 72 hours.

Q: Can I get Cresemba covered if it's not on my formulary? A: Yes, through formulary exception process. Your doctor must demonstrate medical necessity and why formulary alternatives aren't suitable.

Q: What if I'm already taking Cresemba when I switch to Humana? A: New Humana members have a 90-day grace period before prior authorization is required for ongoing specialty medications.

Q: Does Washington state law help with insurance appeals? A: Yes, Washington provides strong consumer protections including mandatory external review by independent medical experts and Insurance Commissioner assistance.

Q: Can I use any specialty pharmacy for Cresemba? A: No, you must use Humana's network specialty pharmacies, primarily CenterWell, to utilize your prescription benefit.

Q: What happens if my appeal is denied? A: You can request external review through Washington's Independent Review Organization, which provides a binding decision from independent specialists.

About Counterforce Health: Counterforce Health helps patients, clinicians, and specialty pharmacies turn insurance denials into successful appeals by creating evidence-backed, payer-specific rebuttal letters. Our platform analyzes denial reasons and drafts targeted appeals using the right clinical evidence and procedural requirements for each insurance plan.

For complex cases or multiple denials, Counterforce Health can help strengthen your appeal with payer-specific documentation and proven strategies that address Humana's specific coverage criteria.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and is not medical advice. Always consult with your healthcare provider about your specific medical condition and treatment options. Insurance coverage varies by plan and individual circumstances. Verify current requirements with your insurance provider and refer to official plan documents for definitive coverage information.

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